Pelvic Health Patient Intake Form Name: Date: Please answer the following questions as honestly and thoroughly as you can. Your responses will help us better understand your condition and provide the best quality of care. For which symptom(s) are you seeking treatment? URINARY Incontinence (bladder control, involuntary loss of urine) Urgency (overwhelmingly strong urge to urinate) Frequency (too frequent voiding) BOWEL Incontinence (bowel control) Problem with Bowel Emptying Problem with Bowel Urgency OTHER Pelvic Organ Prolapse (bulge or protrusion into the vagina) Pelvic Pain How long have you had the above problem(s)? What treatments have you tried? Have you had any tests or imaging? Urodynamic / Cystoscope / Ultrasound / MRI / Colonoscopy / Other Have you had any back, hip, sacral, or pelvic injuries? Have you had any back, hip, pelvic, or abdominal surgeries? Do you currently have any back, hip, or pelvic pain?
Bladder Symptoms How many times per day do you urinate? How many times do you get up to urinate during the night? Do you have difficulty starting urination? Do you strain or push to urinate? Is your urine flow weak or intermittent? Do you leak immediately after voiding (upon standing or as you walk away from the toilet)? Do you feel like you fully empty your bladder? Do you get frequent bladder infections? Are you able to stop your flow of urine intentionally? / NEVER TRIED Urine Leakage How often do you leak? Never About once a week or less Two or three times a week About once a day How much urine do you think you leak? None A small amount A moderate amount A large amount Several times a day All the time Overall, how much does leaking urine interfere with your everyday life? 0 1 2 3 4 5 6 7 8 9 10 (not at all) (a great deal)
How many pads do you use per day? Do you associate any of the following activities with urine loss? Coughing Sneezing Laughing Jumping Sit to Stand Bending Exercise Sleeping Lifting Anxiety/Stress Intercourse Bowel Symptoms Have you ever seen blood in your stool? / HEMMRHOIDS How many bowel movements do you have? per day per week Which bowel symptom(s) do you experience? Loose Stool Normal Stool Constipation Fecal Incontinence Unable to Control Gas Strain to Pass Stool Do you get a strong sense of urgency to have a bowel movement? Do you feel your bowels are completely empty after you have a bowel movement? Do you lose stool unintentionally if your stool is loose? is well formed? Do you take any fiber supplements, laxatives, or stool softeners? Sexual Symptoms Are you sexually active? Do you have any sexually transmitted diseases? If yes, please list:
Do you experience any pain, dysfunction, or discomfort with sexual activity? Have you ever been forced to engage in sexual activity against your will? Marital Status: Do you feel safe in your current relationship? Pain If you have pain related to the condition you are seeking treatment for, please indicate the severity of the pain. 0 1 2 3 4 5 6 7 8 9 10 (no pain) (the worst pain you can imagine) Where is the pain? Please describe the quality of the pain (sharp, burning, ache, etc.) Why do you think you have this pain? What do you think caused your symptoms? Obstetric History How many pregnancies have you had? How many children have you given birth to? Vaginal Cesarean Did any of your deliveries include: Tearing Forceps Episiotomy Vacuum Delivery Baby 8.5 lbs+ Prolonged Second Phase Other:
Menstrual History When was your first period? Are you pregnant? Do you use birth control? What type? Are you going through or have you gone through menopause? Are you using any hormone replacement? What type? General What is your occupation / what activities fill most of your time? What is your current activity level (sedentary, light, moderate, heavy)? What do you do for exercise? Do you have any allergies to latex, tape, or other topicals? Goals What are your goals for treatment? What activities, specifically, are difficult or are you unable to perform due to the condition you are seeking treatment for today? 1. 2. 3.